Nursing Elites

1. A client with diabetes mellitus is experiencing diabetic ketoacidosis (DKA). What laboratory result should the nurse monitor closely?

• A. White blood cell count of 15,000.
• B. Blood glucose level of 320 mg/dL.
• C. Sodium level of 145 mEq/L.
• D. Serum creatinine level of 1.0 mg/dL.

Correct answer: B

Rationale: A blood glucose level of 320 mg/dL indicates the need for insulin to manage diabetic ketoacidosis.

2. A client with a head injury reports severe nausea. What is the nurse's priority action?

• A. Administer anti-nausea medication as prescribed.
• B. Prepare the client for a CT scan.
• C. Elevate the head of the bed and provide an emesis basin.
• D. Notify the healthcare provider immediately.

Correct answer: D

Rationale: Severe nausea in a client with a head injury may be a sign of increased intracranial pressure. The nurse should notify the healthcare provider immediately to ensure timely intervention, as increased pressure can lead to further complications such as brain herniation. Administering anti-nausea medication or preparing for a CT scan may delay necessary treatment for the underlying cause of the nausea, which could be related to the head injury. Elevating the head of the bed and providing an emesis basin may help manage symptoms but should not be the priority over addressing the potential increase in intracranial pressure.

3. The nurse is assessing a client with a new diagnosis of hyperthyroidism. Which assessment finding should the nurse expect?

• A. Decreased heart rate
• B. Increased appetite
• C. Cold intolerance
• D. Weight gain

Correct answer: B

Rationale: In hyperthyroidism, there is an increase in metabolism, leading to symptoms such as increased appetite, weight loss, and heat intolerance. Therefore, the nurse should expect an increased appetite in a client with hyperthyroidism. Choices A, C, and D are incorrect because decreased heart rate and cold intolerance are more commonly associated with hypothyroidism, while weight gain is not typically seen in hyperthyroidism.

4. A client with chronic renal failure has a potassium level of 6.5 mEq/L. What is the nurse's priority action?

• A. Administer a potassium supplement.
• B. Notify the healthcare provider immediately.
• C. Administer calcium gluconate.
• D. Restrict the client's potassium intake.

Correct answer: B

Rationale: A potassium level of 6.5 mEq/L indicates hyperkalemia, which can lead to life-threatening arrhythmias. The correct priority action for the nurse is to notify the healthcare provider immediately. Hyperkalemia requires prompt intervention to lower potassium levels and prevent complications. Administering a potassium supplement (Choice A) would worsen the condition. Administering calcium gluconate (Choice C) is a treatment option but is not the nurse's priority action. Restricting the client's potassium intake (Choice D) may be necessary but is not the immediate priority when facing a critical potassium level.

5. A client receiving full-strength continuous enteral tube feeding develops diarrhea. What intervention should the nurse take?

• A. Stop the feeding and provide IV fluids.
• B. Dilute the feeding to half strength and continue at the same rate.
• C. Reduce the feeding rate and monitor for improvement.
• D. Add fiber to the client's diet to resolve diarrhea.

Correct answer: B

Rationale: When a client develops diarrhea from continuous enteral tube feeding, diluting the feeding to half strength and continuing at the same rate is the appropriate intervention. This helps reduce the strength of the feeding, minimizing gastrointestinal upset while still providing necessary nutrition. Stopping the feeding abruptly (Choice A) may lead to nutritional deficits. Simply reducing the feeding rate (Choice C) may not effectively address the issue of diarrhea. Adding fiber (Choice D) could potentially worsen the diarrhea in this scenario instead of resolving it.

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